Published in the November 2016 issue of Today’s Hospitalist
A READER sent in a question that prompts a ﬂood of billing and coding queries to physicians every day: How should doctors and hospitals handle information that’s pending at discharge and that ultimately changes diagnoses? Here’s a look at that question and my answer.
Our hospital is now following patient results post-discharge for items such as pathology, then requesting an amendment to a discharge summary if a better-paying diagnosis presents itself.
For example, a patient who was discharged with a diagnosis of acute hypoxic respiratory failure and COPD exacerbation had a chest mass collected during the hospital stay for biopsy. After discharge, the biopsy proved to be cancer.
Either there is or there isn’t clinical evidence to support changing a diagnosis.
Now, the hospital requests a change in the discharge summary, treating these queries as a chart deﬁciency that providers need to correct. Our physicians want an opinion on adding a diagnosis post-discharge.
This is an age-old quandary that accounts for the majority of queries made to physicians after patients are discharged. As I read it, you really have two questions: Should you and your colleagues modify your discharge summaries to include new (and, in this case, critically important) information not available at discharge? And two, is it OK for your hospital to use post-discharge ﬁndings to potentially bill for a higher-level DRG?
If the attending physician documents a “lesion,” “lump” or “mass” in the record and the pathologist— even post-discharge—documents “carcinoma” or “malignancy,” clariﬁcation from the attending physician would be indicated. According to AHIMA’S “Standards of Ethical Coding,” coders may not “misrepresent” the patient’s clinical picture through incorrect coding or by omitting diagnosis or procedure codes.
As for changing the discharge summary: It could be considered a breach of professional ethics if a pathology report documented a deﬁnitive diagnosis that was not included in that ﬁnal summary. Your hospital’s health information management prepares a patient’s medical record for abstraction, determining the principal diagnosis and assigning a DRG after record review. When department members note a discrepancy between the discharge diagnosis provided by the attending and the pathologist, they send a query to the attending physician. Answering that query is certainly important from the perspective of revenue, but it also could be extremely consequential from a medicolegal point of view as well.
As for how you should modify the discharge summary, health information management departments typically have strict guidelines on how to do so. Check with that department and follow its guidance. One helpful reference to consider is the ICD-10-CM Official Guidelines for Coding and Reporting, which are sanctioned by organizations such as the CMS, NCHS, AHA and AHIMA. Section I, chapter 2 (Neoplasms, General Guidelines) may provide useful information as well as section II, part A. In addition, query guidelines published jointly by AHIMA and ACDIS advise hospital coders to generate a query when they note conﬂicting information and documentation in the medical record.
Then there’s the issue of whether modifying a discharge summary could affect payment. Your professional charges for a discharge summary would not likely be affected by an additional diagnosis. Discharge summaries are based on speciﬁc documentation criteria and time, and modifying a discharge summary by changing a diagnosis probably won’t mean the difference between billing a 99238 (hospital discharge of 30 minutes or less) and a 99239 (hospital discharge of more than 30 minutes). You already did the work that went into determining the discharge code.
Hospitals, however, are paid a DRG, which most certainly would be affected if either the principal or secondary diagnoses—along with complications or comorbidities, major or otherwise—change as a result of pathology ﬁndings. Most hospitals do not submit claims for inpatient stays until all the information needed to determine that DRG is available. If a pathology report is pending, hospitals typically hold up a claim until the report has been received.
Would modifying a claim based on results not available at discharge raise “red ﬂags” that could land the hospital in hot water in terms of an audit? I see that being an issue only if there is no justiﬁcation (other than ﬁnancial) for such a modiﬁcation. Either there is or there isn’t clinical evidence to support changing a diagnosis. In the scenario you describe, there deﬁnitely is.
If a hospitalist admits a patient and then requests a consult from three different specialists, can those specialists also bill for initial hospital care?
When the attending physician bills initial hospital care, s/he should select the appropriate level of care for the service rendered (99221-99223) and append the AI modiﬁer. That modiﬁer indicates that the attending provided initial hospital care.
Any specialists who subsequently see the patient may also bill initial hospital care codes for their ﬁrst inpatient visit with that patient, but they can’t append the AI modiﬁer. According to the Medicare Claims Processing Internet-Only Claims Processing Manual 100-4 (chapter 12, section 220.127.116.11, sub-section F), those specialists may also bill a subsequent hospital visit (99231–99233), even if it is their ﬁrst encounter with the patient during the inpatient stay. They might prefer to bill a subsequent visit because they may not meet criteria for billing an initial encounter.
So to answer your question: Yes, three specialists may each bill an initial visit to one patient, as can the admitting hospitalist.
Sue A. Lewis, RN, CPC, PCS, is a coding manager for a nonproﬁt health plan in the Midwest. Send any billing and coding questions you have to her at email@example.com and we may answer them in a future issue.